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Prophy vs Perio Maintenance and insurance

Hello! Since I’ve started 3 years ago in dental hygiene this is an issue that continuously gets brought up by patients… “Why do I need to have a periodontal maintenance appointment…can’t I just have a regular cleaning?” Or “Why am I getting charged now for a cleaning, I never had to pay before” “I don’t want to come in every 3 months, I only want to come for what my insurance covers”

I try to maneuver the waters with patients as best as I can…first explaining s/rp therapy, periodontal maintenance, and changing of their recall frequency. Once they’ve had s/rp therapy then re-explaining PM and frequency. But lets be honest, patients forget everything we’ve talked about once they see the insurance coverage, or lack there of.

My concern is that legally, after s/rp is done, isn’t the patient now under PM no matter what? But what happens when a patient refuses a periodontal maintenance appointment? Can you charge it out as a prophylaxis? (I’ve tried to explain many times to patients that they are no longer getting a preventative cleaning, they have periodontal disease and this is the type of cleaning they need now…. )

What dialog do you all use? Any techniques that the front desk can use to help with the above questions they get from patients?

Thanks everyone, I know this was kind of all over the place!

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1 Answer

Your dialogue sounds much like what I would say. I like to educate on periodontal disease first, then let that lead to why a more frequent recare schedule is needed. For instance and in a nutshell: When bacteria/plaque is not removed or disrupted by proper homecare, the bacteria becomes stronger the longer it sits. It first causes puffiness and bleeding of the gums, which is reversible (gingivitis). However, the longer it sits undisturbed, it gets stronger which leads to the bone and gums holding the teeth in to break down, which could cause tooth loss (periodontitis). Gums and bone don’t grow back. It is important to come in more frequently to remove this toxic bacteria because, while this disease cannot be “cured” it can be maintained. This bacteria can grow back within months, which is why 6 months is too long. I also like to add that infection/inflammation in the mouth has been linked to other bodily diseases such as heart disease, Alzheimer’s, stroke, diabetes, preterm/low birth weight babies, etc. Again, this is a reason why the virulent bacteria that the patient is swallowing all day, everyday, and that is entering the bloodstream, needs to be kept in check by more frequent recalls. Like you, I explain the difference between a preventive cleaning (prophy) and how maintenance of disease (perio maint.) is different. The patient is in a disease-state and it needs to be treated as such.

After SRP is done, a patient is perio maintenance, not a prophy and should not be billed as such. To bill for anything else constitutes insurance fraud. Which is not something the office or the patient wants to be a part of. To do so can also be seen as managed neglect/supervised neglect. On the same note, when you do bill, you cannot alternate prophy/PM, but you can write a narrative saying that if periodontal maintenance (D4910) is denied, please provide the alternative benefit of prophylaxis (D1110). Only the insurance company can down-grade services, you must submit what treatment is actually done. If a patient only wants to come in every 6 months, still bill PM. Thoroughly chart that you have explained the need for a more frequent recall, but the patient has refused. Have them signed a refusal form, so they have skin in the game. Remember though, that a refusal form will not stand up in court as its still the dental office’s obligation to abide by the standard of care.

Another question similar to this has been asked and another hygienist (Debi) added, “I would add that the insurance companies are not in the healthcare industry, they are a for-profit business working with a focus of increasing their revenues. I recommend to my patients they call their insurance carrier and find out why they will not cover the necessary treatment to keep them healthy. Also, depending on the patient, it may be less expensive to be a cash payer instead of paying high premiums for dental “insurance”.”

It’s a tough situation and all you can do is educate, even though you sound like a broken record and feel like you are just spinning your wheels. You can only lead a horse to water, you cannot make them drink!

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